COPD – what kind of disease is it?

COPD – chronic obstructive pulmonary disease – is a common, incurable respiratory disease, which is usually the result of smoking and is manifested by symptoms such as coughing, sputum production and shortness of breath. The disease often develops insidiously and progresses in stages. As it goes, the lung tissue is increasingly destroyed, and breathing becomes increasingly difficult. The body no longer gets enough oxygen, and life expectancy is reduced. Here, you can find out more about the causes, stages and therapy of the so-called smoker’s lung.

Definition: What is COPD?

The abbreviation COPD stands for the English term Chronic Obstructive Pulmonary Disease. In medicine, obstructive or obstruction describes a blockage or a narrowing – in this case, it means an airway obstruction, i.e. the narrowing of the airways.

There are different definitions of what COPD is. It is usually defined as a chronic (i.e. permanent) and usually progressive (advancing) disease of the lungs and airways, in which the latter becomes increasingly narrow. This narrowing cannot be wholly reversed (reversed) even by medication and impairs lung ventilation, i.e. the ability to “ventilate” the lungs during breathing by expanding and contracting the chest cavity. This process is often the result of chronic inflammation in response to noxious gases or particles.

COPD is a collective term for two different chronic respiratory diseases that can exist together or separately: chronic obstructive bronchitis and pulmonary emphysema.

 

Chronic obstructive bronchitis and pulmonary emphysema

Chronic obstructive bronchitis (COB) is a chronic inflammation of the airways that leads to the narrowing of the bronchi. This form of bronchitis is a persistent cough (usually with sputum) associated with a permanent airway obstruction.

In pulmonary emphysema, the so-called alveoli, which are required for gas exchange, i.e. the exchange of oxygen and carbon dioxide, are overstretched and partially destroyed. Chronic overinflation of the lungs develops, primarily impairs exhalation and reduces oxygen content in the blood.

Causes and risk factors

Various factors can be involved in the development of COPD. The irritation caused by external influences plays a central role. Most patients smoke or have smoked in the past. Because smoking is the cause of COPD in about 90 per cent of cases, the disease is colloquially referred to as a smoker‘s lung. Regular passive smoking is also one of the possible triggers.

However, in addition to tobacco smoke, there are also other possible causes, such as severe air pollution (particulate matter) or, for example, frequent contact with chemicals, dust or gases at work.

Since the lung disease runs more frequently in some families, it is also being discussed whether COPD can be inherited. In addition, a genetically determined AAT deficiency can be the cause in rare cases. This hereditary disease lacks the enzyme AAT (alpha-1-antitrypsin) needed to protect the air sacs in the lungs. A lack of this enzyme can promote the destruction of the airways. Impaired lung development in the womb and frequent respiratory infections in childhood are also possible causes of chronic obstructive pulmonary disease.

Men get sick much more often than women. According to estimates, around five to ten per cent of adults over the age of 40 are affected – COPD is, therefore, far more common than asthma. COPD is still one of the leading causes of death worldwide.

 

Emergence: How does COPD start, and what happens during it?

COPD often includes two aspects: inflammation of the bronchi and overinflation of the lungs. Both clinical pictures often occur together; the transition can be fluid.

Constant inflammatory processes caused by the frequent contact of the lungs with irritating pollutants are often the starting point of COPD. The permanent inflammation in the respiratory tract results in a narrowing of the bronchi: cilia are located on the inner walls of the bronchi, which generally use a thin, sticky layer of mucus to trap pathogens or dust before they penetrate the lungs and transport them outside.

However, the constant inflammation causes the cilia to be destroyed, and at the same time, more mucus is produced. Due to the lack of evacuation of the mucus, the bronchi become clogged and narrow. This effect is amplified because the mucous membranes swell, and the muscles around the bronchi contract.

Pulmonary emphysema often develops as a result of the chronic irritation just described. Destruction occurs in the air sacs in the lungs (alveoli). An imbalance between the degrading and protective enzymes breaks down their delicate, elastic walls. Many tiny bubbles become a few large bubbles. This reduces the inner surface of the alveoli, which is required for gas exchange. The absorption of oxygen in the blood is impaired.

And: Due to the reduced elasticity, the lungs no longer contract by themselves when exhaling. It is becoming increasingly challenging to exhale the stale air – the lungs overinflate, yet there is less and less space to breathe in fresh, oxygen-rich air.

Recognize symptoms of COPD.

COPD develops insidiously over several years because the lungs can compensate for an increasing loss of function long before severe symptoms appear. Symptoms can vary depending on whether COPD is caused by chronic obstructive bronchitis pu, pulmonary emphysema, or a combination of both. However, possible signs are:

• chronic cough, especially in the morning
• Expectoration when coughing from bronchitis
• Shortness of breath (dyspnoea), which becomes more and more severe as the disease progresses, initially only occurs with exertion, but in the advanced stage, even with slight exertion (such as dressing and undressing) or at rest.
• Difficulty exhaling (prolonged exhalation) and occasional chest tightness
• wheezing or rumbling breath sounds
• in later stages, broad, bloated chest (barrel thorax) due to pulmonary emphysema

Initially, the signs are often mistaken for “normal” smoker’s cough or asthma. A sudden onset of shortness of breath is typical of asthma.

Signs of an exacerbation

Usually harmless respiratory infections such as colds or sore throats, but also fever, heat, cold, increased humidity or exhaust fumes, for example, can cause symptoms to worsen suddenly. For example, this manifests in an increased cough, discoloured sputum or a strong feeling of tightness in the chest. This can also result in general symptoms such as fever, extreme tiredness, aching limbs, suddenly reduced performance, and severe complaints such as cardiac arrhythmia.

Such a paroxysmal, acute worsening that lasts at least two days is called an exacerbation or acutely exacerbated COPD (AECOPD). Treatment in the hospital is often necessary.

 

How is the diagnosis made?

COPD should always be considered in the event of shortness of breath under stress and prolonged coughing and sputum production (so-called AHA symptoms), especially if the person concerned is or was a smoker and is over 40 years old.

The diagnosis is confirmed with the help of so-called spirometry. This is a test to assess lung function by measuring the volume of breathing. In addition, a so-called whole-body plethysmography can be used to measure lung function. Blood tests, imaging tests to assess the lungs (X-ray, CT), laboratory examination of the sputum, blood gas analysis, stress tests, and heart and breathing sounds assessment can also help establish the diagnosis.

Other causes of the symptoms, such as asthma, cystic fibrosis, cardiac insufficiency or lung cancer, should be ruled out. For example, bronchodilator drugs can be administered to check for asthma.

While the family doctor’s practice is the first point of contact, more specific examinations are usually carried out in a specialist practice for pulmonology or pneumology (lung medicine). The examinations allow a statement of how far the disease has progressed and thus enable the doctor to determine the proper treatment.

complications and course

In the advanced stage, the blood no longer contains enough oxygen, which can lead to further symptoms – the disease then gradually affects the whole body. Typical are, for example, substantial weight loss, a change in metabolism and a decrease in bone density and muscle mass. Anaemia, discolouration of the skin and fingernails due to cyanosis (lack of oxygen saturation in the blood), anxiety and depression can also occur.

As a result of the increasingly reduced physical performance, many of those affected also begin to move less, which leads to the breakdown of the muscles and causes the performance to drop even further.

Because the heart has to work harder to get enough oxygen around the body, part of the heart muscle can thicken (cor pulmonale), and the heart weakens. Water retention (oedema) can be the result. Pneumonia or pneumothorax (air accumulation in the chest) are also possible complications.

If left untreated, COPD is usually fatal. Increasing shortness of breath often marks the end of the lung disease. But, respiratory failure is often not the cause of death because impaired lung function increases the risk of cardiovascular diseases such as heart attacks and strokes. COPD reduces life expectancy by an average of five to seven years. However, this prognosis can be improved with optimal therapy.

COPD: classification into stages and groups

Depending on the severity, four stages of COPD are distinguished. The subdivision of these levels goes back to the Global Initiative For Chronic Obstructive Lung Disease (GOLD). An important criterion is the FEV1 (“one-second capacity”), i.e., the air that those affected can exhale within one second with the most significant effort. The value is determined in comparison to the average value of a healthy person (target value). The lower the FEV1 value, the more severe the COPD and the poorer the prognosis.

These stages are distinguished in COPD:

• GOLD 1 (mild): FEV1 is at least 80% of what is predicted at this early stage.
• GOLD 2 (moderate): The FEV1 value is between 50 and 79 percent.
• GOLD 3 (Hard): A score below 50 but at least 30 per cent indicates the third stage.
• GOLD 4 (very severe): In the final stage, the FEV1 value is below 30 per cent.

In addition, groups A to D are differentiated based on the symptoms and the number of exacerbations or hospital admissions. For example, the standardized COPD Assessment Test (CAT score) or the Modified British Medical Research Council Questionnaire (mMRC) are used to assess the symptoms. The choice of therapy is often made in stages according to these ABCD groups.

 

Therapy of COPD

The earlier chronic obstructive pulmonary disease is recognized and treated, the better. However, since lung disease is often only recognized late, early treatment is often impossible.

COPD is not curable. Therefore, the therapy aims to slow the progression of the disease or even stop it completely, as well as alleviate the symptoms and thus improve the quality of life of those affected. The focus is improving lung function, increasing resilience and reducing shortness of breath.

Those affected must know about their illness and take it seriously – even if it may initially only appear as a persistent cough. Disease management programs (DMP) are designed to help those affected to learn how to deal with their disease. Without therapy and lifestyle changes, COPD progresses rapidly and leads to progressive impairments and even death.

Drug and surgical therapy

Various medications can be used to treat COPD, depending on the severity of the disease, the symptoms present, and the individual’s response to the medication. They are usually inhaled or taken as tablets.

Possible medications are:

• anti-inflammatory agents with cortisone or PDE-4 inhibitors
• Bronchodilators to widen the airways (beta-2 mimetics, anticholinergics, and methylxanthines such as theophylline)
• expectorants that make it easier to expectorate (much pharmaceuticals) or cough suppressants (antitussives)
• possibly antibiotics for acute infections

In advanced cases, ventilation is sometimes required to supply oxygen.

Sometimes, surgery may also be necessary. In the case of severe pulmonary emphysema, for example, the overinflated lung can be surgically reduced (lung volume reduction or bullectomy). A lung transplant can also be performed under certain conditions.

Supportive care: what can you do yourself?

Anyone who smokes should give up smoking as soon as possible – even if it is difficult. A doctor’s consultation can help to find the right strategies for quitting smoking and, for example, provide information about methods such as nicotine replacement therapy. If those affected are exposed to pollutants  at the workplace, it should be checked whether protective measures can be taken or whether a workplace change should be considered.

Physical activity is an essential pillar of treatment for COPD. Even when performance is impaired, and sufferers are limited by their shortness of breath, they need physical activity to improve endurance. Suitable lung sports include walking, swimming, dancing or tai chi.

Breathing exercises and the proper breathing techniques  (e.g., “pursed lips” and “coach seat”) are also of great importance in the therapy of COPD, as they train the respiratory muscles and teach them how to cough up mucus better. Such respiratory therapy methods can be practised under expert guidance as part of physiotherapy. Inhalations can also help, for example, to liquefy the bronchial secretion and make it easier to cough up.

In addition, diet in COPD can play an essential role in strengthening the immune system, reducing excess weight, providing the body with sufficient energy, and consuming enough protein to maintain respiratory muscles.

Psychological support should also be part of the treatment. The exchange in self-help groups can help those affected better deal with the disease and its consequences for everyday life or motivate each other.

The so-called peak flow measurement is used to self-monitor lung function. Patient diaries can also help to keep an eye on the course of the disease and, if necessary, to adjust the therapy after consultation with the doctor.

 

Prevent an exacerbation

It is also essential to counteract possible triggers of an exacerbation, i.e. a sudden worsening of the symptoms, and to protect yourself against infection with respiratory tract infections, for example. The well-known measures to safeguard against coronavirus (avoid crowds, wash hands, wear mouth and nose protection) can also be helpful during the cold season. Vaccinations against COVID-19, pneumococci and influenza may also be advisable.

Knowing other possible triggers of such an acute deterioration is also essential. These include, for example, air travel or taking certain medications.

People with COPD should also know what to do in the event of an exacerbation. Individual emergency plans describe what indicators indicate an exacerbation, what medication to take and when medical attention is required. Because a sudden worsening of shortness of breath in COPD sufferers often triggers anxiety, which in turn can worsen the shortness of breath, such measures also serve to provide those affected with security.